Healthcare Provider Details

I. General information

NPI: 1043453640
Provider Name (Legal Business Name): COASTAL ORTHOPEDICS & SPORTS MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 VISTA WAY SUITE B
OCEANSIDE CA
92056-4514
US

IV. Provider business mailing address

3998 VISTA WAY SUITE B
OCEANSIDE CA
92056-4514
US

V. Phone/Fax

Practice location:
  • Phone: 760-724-5173
  • Fax:
Mailing address:
  • Phone: 760-724-5173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RODMAN ST. CLAIR SR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-605-8000